Referral Form

Use this service to submit your interest in receiving short-term counselling or mentoring from YPI Counselling. This service is primarily available to young people within the Basingstoke and Deane area.

YPI Counselling is not a Crisis service and a waiting list system is in place. We see all clients in order by the date of when a referral is received.

We offer short-term counselling which may not be safe or effective if you have a severe mental health condition such as PTSD, an eating disorder, or personality disorder. We recommend talking to your GP about a referral to CAMHS or mental health services.


If you need urgent help or support in a crisis

If you need more immediate support please consider the following:

  • Request an urgent appointment with your GP
  • Attend your local A&E department
  • Call NHS 111 or 999
  • Text SHOUT to 85258
  • (Under 18's) Contact Child Line on 0800 111
  • (Over 18's) Contact the Samaritans on 116 123
  • Online chat: www.kooth.com
  • Self-help: www.youngminds.org

Please note we cannot work with people under an Adoption or Special Guardianship Order. Please contact Barnardo's for further information and support or see link below:

www.barnardos.org.uk/what-we-do

Before you start

You can also register by printing off our referral form.

You cannot register for this service if you live outside of the UK.

Submission takes around 10 minutes.



Self Referral Form


Is this referral



Information about the person having counselling or mentoring


Date of Birth


Which sexual orientation do you identify as?


Contact information

Please provide a phone number and email address that you consent to YPI using to make and confirm appointments with you.

Emergency contact information

Please provide a phone number for use in an emergency.

Work/Education Status


Do you have a disability or a mental health condition?

Please only provide this information if you have been diagnosed by a Health Professional such as a doctor, consultant, or psychiatrist.
Please provide details:
1

What are the main reasons you would like to have counselling support?

Please tell us about the problems you are having with your mental health, feelings, relationships or other issues in your life.

Do you have any thoughts or behaviours which could cause harm to you or others?

For example, let us know if you are self-harming, making plans to take your life, regularly taking drugs or drinking a lot, or feeling violent towards others.

Are you currently receiving any mental health treatment or support?

Please provide details:
1

Are you a parent and under 18?


Are you a young carer?

Please state who you care for and why.

Do you suffer from poverty issues?

Please give more information.

Are you currently in care, or under the Child Protection Plan or Child In Need Plan?

Please give more information.

Are you involved with the Courts?

For example, are you part of an ongoing police investigation, being called as a witness or have you committed a criminal act.
Please give more information.

If you are a parent, guardian, or professional completing this form on behalf of a child or young person, please complete your own details:

If you are this individual's parent or guardian, please leave this blank.

How did you hear about YPI?


Would like to receive YPI’s Quarterly Newsletter with updates on our services, fundraising, and signposting information?

If you would like this to be sent to a different email address to the one you entered earlier, please enter it here:

Please acknowledge the following statement:

Any child 14 years and under must be accompanied by an appropriate adult to and from appointments.

Please acknowledge the following statement:

YPI staff shall ensure that the young person safely leaves the Orchard building however parents acknowledge that it is their responsibility to ensure the safety and well-being of the young person once they have left the premises and must arrange a safe travel route home with them.

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